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									GIFT ANNUITY                                                                                        State of Wisconsin
ANNUAL STATEMENT PACKET                                                                 Office of the Commissioner of Insurance
                                                                                                      P. O. Box 7873
Ref: Section 601.42, Wis. Stat.
                                                                                                Madison, WI 53707-7873




TO: Gift Annuity Insurers


Your annual statement packet is attached.

This annual statement is to be completed by all charitable organizations that are licensed by the State of Wisconsin, Office
of the Commissioner of Insurance (OCI), to issue charitable gift annuities under ch. 615, Wis. Stat. The annual statement
reports the financial status of the segregated account established by the charity to account for the activity of its gift
annuities.

Send the completed annual statement, the certificate of valuation of reserves on a calendar-year basis, the schedule of
fees, and a $50.00 fee for filing and continuation of license. The annual statement must be completed on a nationwide
basis, not a Wisconsin basis, unless otherwise approved by OCI. The Certificate of Reserve Valuation is due March 1
and must be signed by an actuary who qualifies under s. Ins 6.12, Wis. Adm. Code. When appropriate OCI will consider
proposals to file an actuarial certification less frequently than annually, where justified by inactivity and alternative
procedures. Failure to comply will result in forfeiture pursuant to s. 601.64, Wis. Stat. An annual statement is to be filed
even if no gift annuities have been issued.

A Gift Annuity who intends to withdraw should complete the following: send a letter of intent requesting to withdraw from
the state of Wisconsin and a statement that no policies have been issued to Wisconsin residents. The original certificate
of authority should be surrendered with the letter of intent to withdraw. Also, provide information regarding the assumption
of the remaining liabilities by an acceptable company.

Gift annuity insurers are reminded that s. 615.10, Wis. Stat., requires that a surplus be maintained of the greater of
$100,000 or 10% of the reserves.

The annual statement and enclosed schedules are due March 1. They should be sent to OCI, P.O. Box 7873, Madison, WI
53707-7873.

Please note the payment form (OCI 27-013) can be located on the OCI Web site at oci.wi.gov/ociforms.htm. The payment
form (OCI 27-013) and check for fees must be submitted by March 1 to Drawer #566, Milwaukee WI 53293.

If you have any questions, please contact Yvonne Sherry (608) 266-0091 or yvonne.sherry@oci.state.wi.us.

Enclosure




OCI 22-080 (R 02/2007)
                                                 ACTUARIAL INSTRUCTIONS

NOTE:     The minimum standards for gift annuity aggregate reserves shall be the same as the minimum standards for
          aggregate reserves for annuity contracts issued by life insurers authorized to do business under chs. 611 or 618,
          Wis. Stat.

                                                Assumed Rate                       Years of Issue of
              Annuity Table                       of Interest                      Annuity Contract

                 Various*                           Various*                    Before Effective Date
                                                                                of s. 623.06, Wis.. Stat.**

         1937 standard annuity                       3 1/2%                     Between effective date of
         mortality table # or                                                   s. 623.06, Wis. Stat., and
         the annuity table for                                                  operative date of
         1949 ultimate #                                                        s. 623.06, sub. (2a), Wis.
                                                                                Stat. ##

         1971 individual annuity                       6%                       On or after operative date
         mortality table #                                                      of s. 623.06 (2a), Wis. Stat.,
                                                                                and before operative date of
                                                                                s. 623.06 (2m), Wis. Stat.,
                                                                                ####

         1971 or 1983 individual                     7 1/2%                     On or after optional
         annuity mortality table                                                operative date (11/8/77) ###

         1983 individual annuity                 Dynamic ####                   After 1982
         mortality table

         Annuity 2000 table                      Dynamic ####                   Optional for issues between 1/1/86 and
                                                                                12/31/98. Used for issues 1/1/99
                                                                                and later

Standards are for single-premium immediate annuities.

     *   Tables in use before effective date of s. 623.06, Wis. Stat.

    **   Effective date is date that company elected to comply with s. 623.06, Wis. Stat. (between May 22, 1943, and
         December 31, 1947). If no election was made, the effective date is January 1, 1948.

    #    Or any modifications of the table approved by the Commissioner. After 1980, any individual annuity table adopted by
         the NAIC and approved by a rule adopted by the Commissioner.

   ##    Operative date of s. 623.06 (2a), Wis. Stat., is the date of written notice of the company's election to comply with
         subsection (2a) (between June 1974 and December 31, 1978). If no election was made, the operative date is
         January 1, 1979.

  ###    Optional operative date—on or after November 8, 1977, a company may elect a 7 1/2% interest rate by filing a
         written notice with the Commissioner.

####     Individual annuities issued in calendar years after 1982 use dynamic interest rates calculated by the method outlined
         in s. 623.06 (2m) (c), Wis. Stat., subject to the company's option to use the previous year's actual rate if the
         calendar year rate change is less than 0.5% [per (2m) (d)].

Reserves should be calculated according to the Commissioner's reserve valuation method as outlined in s. 623.06 (3) and
(4), Wis. Stat.

The Certificate of Reserve Valuation on calendar-year basis will not be accepted by this office unless signed by an actuary
who qualifies under s. Ins 6.12, Wis. Adm. Code.

OCI 22-080 (R 02/2007)
                                                                                                          Reset Form
CERTIFICATE OF VALUATION:                                                                              State of Wisconsin
AGGREGATE RESERVES ON                                                                      Office of the Commissioner of Insurance
OUTSTANDING GIFT ANNUITIES                                                                               P. O. Box 7873
                                                                                                   Madison, WI 53707-7873
Ref: Section 623.06, Wis. Stat.

INSTRUCTIONS:            Have form signed by an actuary qualified under s. Ins 6.12, Wis. Adm. Code, and forward completed
                         form with annual statement to the above address by MARCH 1.


Name of Gift Annuity                                                                                      For Year Ending

                                                                                                          December 31,




                                                Assumed Rate                  Years of Issue                       Amount of
             Annuity Table                        of Interest              of Annuity Contracts                     Reserve


 1.

 2.


 3.

 4.


 5.

 6.


 7.

 8.


 9.   Total Reserve (Lines 1 through 8) (should agree with Page 2, Line 7 of the Annual Statement)                             0.00




I certify that the amount of annuity reserve shown on Line 9 above and in the annual statement of the above-named company has
been correctly computed based upon the schedules and other data submitted to me. The bases used in the valuation are shown
above, and such bases satisfy the requirements of s. 623.06, Wis. Stat.



Actuary Name (Type or Print)             Date                Actuary Signature                       Designation




OCI 22-080 (R 02/2007)
GIFT ANNUITY                                                                                              State of Wisconsin
ANNUAL STATEMENT PACKET                                                                       Office of the Commissioner of Insurance
                                                                                                            P. O. Box 7873
Ref: Section 601.42, Wis. Stat.
                                                                                                      Madison, WI 53707-7873


INSTRUCTIONS:            Return this form, all other applicable required forms, along with the annual statement. Submit fees and
                         payment form to Drawer #566, Milwaukee, WI 53293, by MARCH 1.

Name of Gift Annuity                                                                               Area Code    Telephone Number

                                                                                                    (       )




       I certify that the items checked below have been filed with the Commissioner of Insurance, state of Wisconsin.

                    Gift Annuity Annual Statement

                    Certificate of Valuation: Aggregate Reserves on Outstanding Gift Annuities

                    Gift Annuity Schedule of Fees


       To be sent to Drawer #566, Milwaukee, WI 53293, on or before March 1.

                    Payment Form (OCI 27-013)

                    Check for $50.00




 Title of Officer                                           Name of Officer (Type or Print)



Date                                                        Signature of Officer




OCI 22-080 (R 02/2007)
GIFT ANNUITY SCHEDULE OF FEES                                                                                                        State of Wisconsin
                                                                                                                         Office of the Commissioner of Insurance
                                                                                                                                       P. O. Box 7873
Ref: Section 601.31, Wis. Stat.                                                                                                  Madison, WI 53707-7873


INSTRUCTIONS:               Complete and return form with annual statement. Submit check made payable to the Commissioner of
                            Insurance along with payment form to Drawer #566, Milwaukee, WI 53293, by MARCH 1.



Name of Gift Annuity



State of Domicile Individual Responsible for Preparing Form                                                                                         Telephone Number

                                                                                                                                                    (     )




                                                        For Year Ending December 31,


                Wisconsin Fees

 1.    Annual Statement Filing Fee ........................................................................................................                   $25.00

 2.    Continuation of License Fee .........................................................................................................                  $25.00

 3.    Total Fees Payable .......................................................................................................................             $50.00




Title of Officer                                                               Name of Officer (Type or Print)



Date                                                                          Signature of Officer




                                                                                                                                            For Office Use Only
                                                                                                                                   Initial As Vouchered:
                                                                                                                                   1. To Allocation Screen
                                                                                                                                   2. To Amount in Letter




OCI 22-080 (R 02/2007)
                         ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND
                                  For the Year Ended December 31,

Name of Gift Annuity


Mailing Address


Annual Statement Contact Person                                   E-mail                              Phone Number



NAMES OF OFFICERS:

President

Secretary

Treasurer

NAMES OF DIRECTORS OR TRUSTEES:




State of
County of                                   }s s
                                        ,                         of the
            name of officer                        office                           name of gift annuity issuer
being duly sworn, deposes and says that I am the above described officer of said gift annuity issuer, and that on the
thirty first day of December last, all the herein described assets were the absolute property of said gift annuity issuer free
and clear of any liens or claims thereon, except as herein stated, and that this annual statement is a true and full statement
of all segregated assets and related liabilities of the gift annuity issuer to the best of my knowledge and belief.




                                                                                         signature of officer

Subscribed and sworn to before me this
                    day of




Due March 1 at: State of Wisconsin                                          Street address for hand delivery:
                Office of Commissioner of Insurance                             State of Wisconsin
                PO Box 7873                                                     Office of Commissioner of Insurance
                Madison WI 53707-7873                                           125 S. Webster St.
                                                                                Madison WI 53702
OCI 22-080 (R 02/2007)                                        1
                               ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND


Name of Gift Annuity




                                                       BALANCE SHEET
                                                 As of December 31, _______


Assets

 1. Bonds (Schedule A)                                              $

 2. Mutual Funds and Money Market Funds (Schedule B)

 3. Stocks (Schedule C)

 4. Cash (Schedule D)

 5. Other Assets (Schedule E)

 6. Total Assets (sum of lines 1 to 5)                                               $   0.00



Liabilities and Fund Balance
                                                                              0.00
 7. Aggregate Reserve for Outstanding Gift Annuities                $

 8. Annuity Payments Due and Unpaid

 9. Borrowed Money

10. Other Liabilities Due and Accrued:

     10.1

     10.2

     10.3

     10.4


                                                                                         0.00
11. Total Liabilities (sum of lines 7 to 10.4)                                       $


12. Surplus (line 6 minus line 11)                                                   $   0.00


                                                                                         0.00
13. Total Liabilities and Surplus (line 11+ line 12)                                 $




OCI 22-080 (R 02/2007)                                       2
                            ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND

Name of Gift Annuity



                                    STATEMENT OF CHANGES IN FUND BALANCE
                                     For the Year Ended December 31, _______


 1. Gifts received conditioned on annuity agreements                           $

 2. Investment income
    2.1 Bonds
     2.2 Mutual Funds and Money Market Funds
     2.3 Stocks
     2.4 Cash
     2.5 Other Assets

 3. Other income:
    3.1 Net Realized Capital Gains (Losses)
    3.2 Net Unrealized Capital Gains (Losses)
     3.3
     3.4
     3.5
     3.6

 4. Transfers to Annuity Fund from General Fund

 5. Total Income                                                               $              0.00

 6. Annuity payments                                                           $

 7. General expenses

 8. Other expenses:
    8.1 Increase (decrease) in actuarial reserves from prior year
    8.2
     8.3
     8.4
     8.5
     8.6
     8.7

 9. Transfers from Annuity Fund to General Fund

10. Total Expenses                                                                            0.00

11. Change In Surplus (Line 5 - Line 10)                                       $              0.00

12. Previous Year-End Surplus

13. Surplus End of Year (Line 11 + Line 12)                                    $               0.00
                                                                                    To agree with
                                                                                   Balance Sheet,
                                                                                       Line 12
OCI 22-080 (R 02/2007)                                      3
OCI 22-080 (R 02/2007)

                                                                        ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND


                         Name of Gift Annuity




                                                                                             Schedule A - Bonds
                                                                              Showing all Bonds Owned at the end of Current Year

                                                                                    For the Year Ended December 31, _______

                              1                       2                             3           4          5          6               7             8               9             10
                           Line #                 Description                   Interest     Date of      Par        Cost       Market Value     Market         Change in      Interest
                                                                                  Rate       Maturity    Value                   Beginning      Value End       Unrealized     Received
                                                                                            Month/Year                            of Year*       of Year         Capital      During Year
                                                                                                                                                               Gain or Loss
                                                                                                                                                                8 minus 7
                           4102                                                   0.000%
                           4103                                                   0.000%
                           4104                                                   0.000%
  4




                           4105                                                   0.000%
                           4106                                                   0.000%
                           4107                                                   0.000%
                           4108                                                   0.000%
                           4109                                                   0.000%
                           4110                                                   0.000%
                           4111                                                   0.000%
                           4112                                                   0.000%
                           4113                                                   0.000%
                           4114                                                   0.000%
                           4115                                                   0.000%
                           4116                                                   0.000%
                           4117                                                   0.000%
                           4118                                                   0.000%
                           4119                                                   0.000%
                           49999    Total – Bonds                               XXXX          XXXX           0.00        0.00           0.00            0.00          0.00           0.00
                                                                                                                                               Balance Sheet
                          * Or at date of purchase for investments purchased during the current year.                                              Line 1
                          Attach additional pages if additional space is needed.
OCI 22-080 (R 02/2007)

                                                                        ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND

                         Name of Gift Annuity




                                                                         Schedule B – Mutual Funds and Money Market Funds
                                                          Showing All Mutual Funds and Money Market Funds Owned at the End of Current Year

                                                                                   For the Year Ended December 31, _______

                             1                            2                                3            4                  5               6               7                  8
                          Line #                      Description                        Number        Cost          Market Value       Market         Change in         Dividends
                                                                                           of                         Beginning        Value End       Unrealized        Received
                                                                                         Shares                        of Year*         of Year          Capital        During Year
                                                                                                                                                      Gains (+) and
                                                                                                                                                       Losses (-)
                                                                                                                                                       6 minus 5
                          5101
                          5102
                          5103
5




                          5104
                          5105
                          5106
                          5107
                          5108
                          5109
                          5110
                          5111
                          5112
                          5113
                          5114
                          5115
                          5116
                          5117
                          5118
                          5119
                          59999 Total Mutual Funds and Money Market Funds                 XXXX                0.00             0.00            0.00              0.00            0.00
                         * Or at date of purchase for investments purchased during the current year.                                  Balance Sheet
                         Attach additional pages if additional space is needed.                                                           Line 2
OCI 22-080 (R 02/2007)

                                                                        ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND

                         Name of Gift Annuity




                                                                                             Schedule C – Stocks
                                                                             Showing all Stocks Owned at the End of Current Year

                                                                                    For the Year Ended December 31, _______

                             1                            2                                 3            4                  5               6                7                8
                          Line #                      Description                         Number        Cost          Market Value       Market         Change in        Dividends
                                                                                            of                         Beginning        Value End       Unrealized       Received
                                                                                          Shares                        of Year*         of Year          Capital         During
                                                                                                                                                       Gains (+) and      Current
                                                                                                                                                        Losses (-)         Year
                                                                                                                                                        6 minus 5
                          6101
                          6102
                          6103
  6




                          6104
                          6105
                          6106
                          6107
                          6108
                          6109
                          6110
                          6111
                          6112
                          6113
                          6114
                          6115
                          6116
                          6117
                          6118
                          69999      Total Stocks                                          XXXX                0.00             0.00            0.00              0.00           0.00
                                                                                                                                       Balance Sheet
                         * Or at date of purchase for investments purchased during the current year.                                       Line 3
                         Attach additional pages if additional space is needed.
OCI 22-080 (R 02/2007)


                                                                       ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND


                         Name of Gift Annuity




                                                                                             Schedule D – Cash
                                                                                 Showing all Cash at the End of Current Year

                                                                                  For the Year Ended December 31, _______



                                         1                                  2                                       3                 4          5
                                      Line #                        Name of Depository                          Interest          Interest    Balance
                                                                                                                  Rate           Received      Current
                                                                                                                                During Year   Year-End
                                      7101                                                                             0.000%
                                      7102                                                                             0.000%
                                      7103                                                                             0.000%
                                      7104                                                                             0.000%
  7




                                      7105                                                                             0.000%
                                      7106                                                                             0.000%
                                      7107                                                                             0.000%
                                      7108                                                                             0.000%
                                      7109                                                                             0.000%
                                      7110                                                                             0.000%
                                      7111                                                                             0.000%
                                      7112                                                                             0.000%
                                      7113                                                                             0.000%
                                      71999     Total Cash In Depository                                                                                 0.00
                                      72999     Cash In Company’s Office
                                      73999     Total Cash                                                                                               0.00
                                                                                                                                              Balance Sheet
                                                                                                                                                  Line 4

                                     Attach additional pages if additional space is needed.
OCI 22-080 (R 02/2007)

                                                                       ANNUAL STATEMENT OF SEGREGATED GIFT ANNUITY FUND
                         Name of Gift Annuity



                                                                                      Schedule E – All Other Assets
                                                                        Showing All Other Assets Owned at the End of Current Year

                                                                                  For the Year Ended December 31, _______

                                     1                                2                                 3             4                   5                6
                                  Line #              Location and Description of Property            Date           Cost             Statement         Income
                                                                                                     Acquired                           Value          Received
                                                                                                                                    (Market Value        During
                                                                                                                                      Less Any         the year
                                                                                                                                   Encumbrances)
                                  8101
                                  8102
                                  8103
                                  8104
  8




                                  8105
                                  8106
                                  8107
                                  8108
                                  8109
                                  8110
                                  8111
                                  8112
                                  8113
                                  8114
                                  8115
                                  8116
                                  8117
                                  8118
                                  8119
                                  8120
                                  8121
                                  89999      Total All Other Assets                                                         0.00                0.00              0.00
                                 Attach additional pages if additional space is needed.                                             Balance Sheet
                                                                                                                                        Line 5

								
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